This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document by calling (866) 868-8541. Important Questions Answers Why this Matters: What is the overall deductible? No Deductible All eligible services are covered 100%. Are there other deductibles for specific services? Is there an out of pocket limit on my expenses? What is not included in the out of pocket limit? Is there an overall annual limit on what the plan pays? Does this plan use a network of providers? Do I need a referral to see a specialist? Are there services this plan doesn t cover? No Deductible No Out of Pocket All eligible services are covered 100%. No Out of Pocket No Yes N/A MultiPlan Not a covered benefit. Yes All services not explicitly outlined in Public Health Service Act 2713 OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146 Corrected on May 11, 2012 1 of 6
Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven t met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) This plan may encourage you to use MultiPlan providers by charging you lower deductibles, copayments and coinsurance amounts. Common Medical Event If you visit a health care provider s office or clinic If you have a test If you need drugs to treat your illness or condition More information about prescription drug coverage please call (866) 868-8541 If you have outpatient surgery If you need immediate medical Services You May Need In-network Out-of-network Limitations & Exceptions Primary care visit to treat an injury or illness N/A N/A Benefit not covered. Specialist visit N/A N/A Benefit not covered. Other practitioner office visit N/A N/A Benefit not covered. Preventive care/screening/immunization 0% 0% Diagnostic test (x-ray, blood work) N/A N/A Benefit not covered. Imaging (CT/PET scans, MRIs) N/A N/A Benefit not covered. Generic drugs 0% 100% Only drugs covered by plan. Preferred brand drugs N/A N/A Benefit not covered. Non-preferred brand drugs N/A N/A Benefit not covered. Specialty drugs N/A N/A Benefit not covered. Facility fee (e.g., ambulatory surgery center) N/A N/A Benefit not covered. Physician/surgeon fees N/A N/A Benefit not covered. Emergency room services N/A N/A Benefit not covered. Emergency medical transportation N/A N/A Benefit not covered. 2 of 6
Common Medical Event Services You May Need In-network Out-of-network Limitations & Exceptions attention Urgent care N/A N/A Benefit not covered. If you have a hospital stay If you have mental health, behavioral health, or substance abuse needs If you are pregnant If you need help recovering or have other special health needs If your child needs dental or eye care Facility fee (e.g., hospital room) N/A N/A Benefit not covered. Physician/surgeon fee N/A N/A Benefit not covered. Mental/Behavioral health outpatient services N/A N/A Benefit not covered. Mental/Behavioral health inpatient services N/A N/A Benefit not covered. Substance use disorder outpatient services N/A N/A Benefit not covered. Substance use disorder inpatient services N/A N/A Benefit not covered. Prenatal and postnatal care N/A N/A Benefit not covered. Delivery and all inpatient services N/A N/A Benefit not covered. Home health care N/A N/A Benefit not covered. Rehabilitation services N/A N/A Benefit not covered. Habilitation services N/A N/A Benefit not covered. Skilled nursing care N/A N/A Benefit not covered. Durable medical equipment N/A N/A Benefit not covered. Hospice service N/A N/A Benefit not covered. Eye exam N/A N/A Benefit not covered. Glasses N/A N/A Benefit not covered. Dental check-up N/A N/A Benefit not covered. Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn t a complete list. Check your policy or plan document for other excluded services.) All benefits not explicitly provided by Public Health Service Act 2716 3 of 6
Other Covered Services (This isn t a complete list. Check your policy or plan document for other covered services and your costs for these services.) Only benefits explicitly listed in Public Health Service Act 2713 Your Rights to Continue Coverage: Standard COBRA rights apply. Please see Summary Plan Description for further details. Your Grievance and Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact: (866) 868-8541 Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al (866) 868-8541 Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa (866) 868-8541 Chinese ( 中文 ): 如果需要中文的帮助, 请拨打这个号码 (866) 868-8541 Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' (866) 868-8541 To see examples of how this plan might cover costs for a sample medical situation, see the next page. 4 of 6
Coverage Examples About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. This is not a cost estimator. Don t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. Having a baby (normal delivery) Amount owed to providers: $7,540 Plan pays $40 Patient pays $7,500 Sample care costs: Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient pays: Deductibles $0 Copays $0 Coinsurance $0 Limits or exclusions $7,500 Total $7,500 Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $5,400 Plan pays $400 Patient pays $5,000 Sample care costs: Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Patient pays: Deductibles $0 Copays $0 Coinsurance $0 Limits or exclusions $5,000 Total $5,000 5 of 6
Coverage Examples Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? Costs don t include premiums. Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren t specific to a particular geographic area or health plan. The patient s condition was not an excluded or preexisting condition. All services and treatments started and ended in the same coverage period. There are no other medical expenses for any member covered under this plan. Out-of-pocket expenses are based only on treating the condition in the example. The patient received all care from innetwork providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn t covered or payment is limited. Does the Coverage Example predict my own care needs? No. Treatments shown are just examples. The care you would receive for this condition could be different based on your doctor s advice, your age, how serious your condition is, and many other factors. Does the Coverage Example predict my future expenses? No. Coverage Examples are not cost estimators. You can t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows. Can I use Coverage Examples to compare plans? Yes. When you look at the Summary of Benefits and Coverage for other plans, you ll find the same Coverage Examples. When you compare plans, check the Patient Pays box in each example. The smaller that number, the more coverage the plan provides. Are there other costs I should consider when comparing plans? Yes. An important cost is the premium you pay. Generally, the lower your premium, the more you ll pay in out-ofpocket costs, such as copayments, deductibles, and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. 6 of 6